cutting. To remove by cutting, cast cutters, spreaders,and bandage scissors are necessary. Cuts are madelaterally and medially along the long axis of the cast,then widened with the use of spreaders. The padding isthen cut with the scissors.THE TERMINALLY ILL PATIENTLEARNING OBJECTIVE: Evaluate theneeds of the terminally ill patient.The terminally ill patient has many needs that arebasically the same as those of other patients: spiritual,psychological, cultural, economic, and physical. Whatdiffers in these patients may be best expressed as theurgency to resolve the majority of these needs within alimited time frame. Death comes to everyone indifferent ways and at different times. For somepatients, death is sudden following an acute illness.For others, death follows a lengthy illness. Death notonly affects the individual patient; it also affects familyand friends, staff, and even other patients. Because ofthis, it is essential that all healthcare providersunderstand the process of dying and its possible effectson people.Individuals Perspective on DeathPeople view death from their individual andcultural value perspectives. Many people find thecourage and strength to face death through theirreligious beliefs. These patients and their familiesoften seek support from representatives of theirreligious faith. In many cases, patients who previouslycould not identify with a religious belief or the conceptof a Supreme Being may indicate (verbally ornonverbally) a desire to speak with a spiritualrepresentative. There will also be patients who,through the whole dying experience, will neitherdesire nor need spiritual support and assistance. In allthese cases, it is the responsibility of the healthcareprovider to be attentive and perceptive to the patientsneeds and to provide whatever support personnel thepatient may require.Cultural InfluencesAn individuals cultural system influencesbehavior patterns. When we speak of cultural systems,we refer to certain norms, values, and action patterns ofspecific groups of people to various aspects of life.Dying is an aspect of life, and it is often referred to asthe final crisis of living. In all of our actions, culturallyapproved roles frequently encourage specific behaviorresponses. For example, in the Caucasian,Anglo-European culture, a dying patient is expected toshow peaceful acceptance of the prognosis; thebereaved is expected to communicate grief. Whenpeople behave differently, the healthcare providerfrequently has difficulty responding appropriately.Five Stages of DeathA theory of death and dying has developed thatprovides highly meaningful knowledge and skills to allpersons involved with the experience. In this theory ofdeath and dying (as formulated by Dr. ElizabethKubler-Ross in her book On Death and Dying), it issuggested that most people (both patients andsignificant others) go through five stages:denial,anger, bargaining, depression, and acceptance.The first stage, denial, is one of nonacceptance.No, it cant be me! There must be a mistake! It is notonly important for the healthcare provider to recognizethe denial stage with its behavior responses, but also torealize that some people maintain denial up to the pointof impending death. The next stage is anger. This is aperiod of hostility and questioning: Why me? Thethird stage is bargaining. At this point, people revertto a culturally reinforced concept that good behavior isrewarded. Patients are often heard stating, Id doanything if I could just turn this thing around. Oncepatients realize that bargaining is futile, they quicklyenter into the stage of depression. In addition togrieving because of their personal loss, it is at this pointthat patients become concerned about their family andputting affairs in order. The final stage comes whenthe patient finally accepts death and is prepared for it.It is usually at this time that the patients familyrequires more support than the patient. It is importantto remember that one or more stages may be skipped,and that the last stage may never be reached.Support for the DyingDespite the fact that we all realize our mortality,there is no easy way to discuss death. To the strong andhealthy, death is a frightening thought. The fact thatsooner or later everyone dies does not make deatheasier. There are no procedure books that tellhealthcare providers how to do death. The how towill only come from the individual healthcare providerwho understands that patients are people, and that,more than any other time in life, the dying patientneeds to be treated as an individual person.2-23